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HomeMy Public PortalAbout5018 BALDWIN AVE_Sewer__ (2) . � 7 CE808 3-62 J • Iglgry 76A642D APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION F LDING � JOHN A. LAMBIE, County Engineer RESSWILLIAM A. JENSEN, Sup't of Building ALITYREST FOR APPLICANT TOFILL IN CROSS ST. SCA�_l LT LEGAL DESCRIPTION LOT NO: 'OWNER / r MAIL �o BLOCK TRACT ADDRESS NO. OF BLDGS. � SIZE OF LOT NOW ON LOT CITY I� TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUyi MAP/ // PROCESSED BY BK CONTRACTOR �t / a./1 /�' ADDRESS ,J ,y CONNECTIO A A 1 %' L CIT TEL. O. aJ ©� STATION DEPTH <7 STATE MANHOLE REFERENCE UPPE f REGISTRATION NO. C G•"� ❑ COUNTY � r NO. DESCRIPTION OF WORK FEE TYPE OF CONNECT IO LENGTH FR }} HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO I. PUBLIC SEWER @ $5.00 `�' �' y P.C.NO. SEPTIC TANK.SEEPAGE PIT OR (� PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVED EASEMENT RECORD.INSTR.NO.—F DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD - EXTN.,CESSPOOL,DRY WELL.MANHOLE @ $5.00 ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST,.W IDEN I NG SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNER'S PERMIT $ z 00 CHARGES AUTHORIZATION TOTAL FEE 17 vlf—I CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. APPROVALS D TE INSPECTOR'S SIGIVAT'URE SIGNED THIS DAY OF 19_ - ryry ,d II OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAT NFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑ PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD CK. M.O. SUPERVISING MECHANICAL ENGINEER CASii ' LALO7 3 0 a.S 0U23 1 0 D 7.00! G